This ideal certainly was also a representation of the reality for some (or many) physicians in the United States well into the 20th century. And one may say that it represents something of an artisanal or pre-capitalist (with regard to the physician) production model, in that the physicians retained control over the means of production and control over the allocation of their time—they were not selling their labor, as it were, to employers.

There have been many changes for the physician and a critical one was indeed articulated by Marx and Engels in The Communist Manifesto, namely that “the bourgeoisie has stripped of its halo every occupation hitherto honored and looked up to with reverent awe. It has converted the physician, the lawyer, the priest, the poet, the man of science, into its paid wage laborers.” What is interesting, however, is how physician employment developed very slowly in this country. Public institutions—the federal institutions responsible for the care of veterans, state institutions responsible for care of the institutionalized psychiatric patients and local governmental institutions responsible for the care of the poor—have employed physicians for a long time, as have, in some cases, academic institutions such as Universities. Outside of those settings, we find few examples of employed physicians in the United States even into the second half of the 20th century. Over the past twenty-five years however, there has been an acceleration, a rise in the phenomenon of employed physicians. And interestingly, some of the historical processes developed so carefully by Marx in Capital with regard to the employment of factory workers can be seen in the issues associated with physician employment—increases in physician productivity, specialization and standardization, but also a loss of physician control over the work process, a sense of alienation from work, conflicts over productivity demands and something of a loss of the ethical orientation previously held.

At the same time, we are witnessing a dramatic number of mergers and acquisitions in the health care industry today. Local hospitals are merging to form larger systems, local systems are merging to form state or regional systems, regional systems are merging to form national systems, larger systems are acquiring smaller systems and all the systems are acquiring physician practices. This is happening now at an unprecedented pace, even to the point where concerns are being raised that this must come to a stop -for several reasons, one of which being that it poses a threat to competition, with the development of monopolies or oligopolies in health care. And, indeed, this is the second stage of capitalism, the stage of monopoly capitalism that we see in the health care industry itself. Once the delivery of health care becomes fully a commodity, this evolution reflects the logical development of capital to bring greater profit (or margin, in the case of nonprofit systems) to the corporations as a function of greater efficiency and competitive advantage, with financial benefits from the economies of scale and also the development of a new focus on system marketing and sales independent from the providers of the services. Health care organizations have thus entered into the finance and insurance aspects of health care. Increased productivity does, in cases, certainly result from this, but this comes with increased cost associated with health care (the industry being largely in the private sphere in the United States). The processes of alienation for the physician become further enhanced, in that, as Henry Braverman established in his study of Frederic Taylor’s scientific management of the factory workplaces in Labor and Monopoly Capital, we see further efforts to separate the control over the care delivery process from those responsible for delivering the care.

How is this evolution in tune with our current stage of development of capitalism, be it Late Capitalism (Ernst Mandel), or postindustrial, or global, or postmodern or hypermodern stage of capitalism? I think that we see this present in a number of different ways in the health care industry in the United States. First, with regard to globalization, there is, of course, the globalization of the labor market itself. The obvious examples of this are outsourcing as present in the health care industry as any other large industry—especially with regard to services such as IT support. But, we see this also in the physician labor market itself, in that physician employment for specialized services is often outsourced to physicians outside of the United States, physicians who are fully licensed and accredited and privileged to work from out of the country. This was first seen in radiology services, especially during after hours (at night or on the weekend) by the so-called “night hawk” services out of the country. As this does not require direct patient contact, merely the digitalization and transmission of images, this was simple to develop. As telehealth services have developed, we are seeing this expand to a broader array of physician services. A more dramatic variation of this is to export the patient, as it were, outside of the United States for specialized physician services. I am not referring here to patients seeking specialized elective surgeries at dramatically lower rates outside of the US (which has been going on for years in areas such as plastic surgery). Rather, I allude to the fact that very large employers are now negotiating with health system groups (hospital/physician enterprises) outside of the US to perform particular procedures such as joint replacements. The foreign systems are able to demonstrate superb outcomes and offer the services at much lower rates than US systems, and the corporations are paying to send patients (and spouses) abroad for these services (to what are often described as first-class hospitals, accredited by US regulators, along with luxury accommodations for the spouses). Some health care systems also now have global reach, both in terms of bringing patients to the US for care, but also in establishing foreign corporate footprints where they are establishing hospitals and physician practices—this is especially true of academic health centers, which are increasingly very large and complex not for profit corporations. This global expansion may also include education, such as foreign medical schools or campuses for the domestic institution. But, even domestically, this stage is characterized by a different relationship between the employed physician and his employer. While there is plenty of evidence of practices of Taylorism in physician management, we also find new dimensions to the physician employer relationship. Thus, for example, there is more direct engagement with employers into the lives (or the very bodies themselves) of employees. Employees’ health is monitored and health status is directly linked to changes in the benefits received by the employee (thus, for example, healthier employees may pay less for their health insurance). Or employers institute “well-being” programs to promote the happiness and health of their employees and shift from the standardization of the work process to opportunities for individualized relationships between the employee and the employer (thus, for example, flexible hours as long as productivity is maintained). Such developments must be interpreted both in a positive perspective insofar as they respond to employee demands or provide additional benefits for the employees, but also, and at the same time, negatively, insofar as we might say they represent a new level of alienation in the workplace (in which the employees are alienated not only from their work but also from their own perspective on the work itself, their affective state) or an intrusion of capital into the mind and bodies of the employees in new ways.

What makes the health care industry now so complex in the United States are the ways in which all three of these shifts—into the three different stages of capitalism—seem in some ways to be happening at the same time here in the US, with a complex array of variations specific to each local setting and even changing within a locality from year to year. For many physicians, it has been a vertiginous experience to work in such a complex and quickly changing world.

(To be continued…)